Going to Great Pains
By Caroline Trent-Gurbuz
The patient was addicted to heroin, recalls Katharine Hindle, M.D., assistant professor of anesthesiology and critical care medicine at the GW School of Medicine and Health Sciences (SMHS). GW Hospital staff screen all incoming emergency room patients for opioid and drug use — it’s standard operating procedure — and Hindle, in talking with the patient, found that he was actively using the drug. Digging deeper, she learned that he was self-medicating for hip pain.
“He was at the point where he was very candid about the fact that he didn’t want to continue,” she says. “His goal was to go home on no additional opioids.”
Managing his pain as part of that goal is precisely what Hindle and the Acute Pain Management Service, led by Paul Dangerfield, M.D. ’95, RESD ’02, B.S. ’89, assistant professor of anesthesiology and critical care medicine at SMHS, can offer. It is, Dangerfield says, the team’s small way of taking a bite out of opioid addiction.
Statistically speaking, opioid addiction has cracked the level of epidemic. Since 1999, sales of prescription painkillers — oxycodone, hydrocodone, morphine, fentanyl, codeine — have quadrupled, according to the Centers for Disease Control and Prevention. Four in five heroin users first become addicted by misusing painkillers, the American Society of Addiction Medicine reports, and drug overdose is the leading cause of accidental death in the country.
Using opioids, Dangerfield explains, is like treating pain with a hammer, rather than a needle: Opioids target pain “in a blunt way, in that they not only target the pain, but they target everything else,” he says, which can lead to undesirable side effects. Dangerfield also warns that bluntly targeting the pain doesn’t completely eliminate it, leading to an escalation in dosage, which puts the patient at higher risk for addiction and other negative side effects (nausea, vomiting, constipation, dysphoria). At GW Hospital, however, the Acute Pain Management Service is combining medications and techniques to more precisely target pain and reduce the need for opioids almost completely.
“We use a number of different medications that work in different ways on the pain, what we call regional anesthesia,” Dangerfield explains. “If people need it, they get opioids — but instead of that being the foundation of what we’re doing, our goal is, through this multimodal pain regime, [to give them fewer] opioids. If people aren’t exposed to them in the first place, they’re less likely to become addicted to them, and their pain is treated effectively.”
Multimodal Pain Management
- IV therapy (morphine)
- Bupivacaine (epidural)
- Muscle relaxant
- Pills (opioids)
After being diagnosed with breast cancer, Robyne Doyle opted for the multimodal approach for her double mastectomy and breast reconstruction because, she says, “I know pain.”
Doyle was a nurse in the GW Hospital ICU for almost 30 years. “I think some people who are not in the medical field don’t have a grasp of how painful that surgery is,” she says. “I was fully aware. It’s not a walk in the park.”
Dangerfield treated Doyle with the paravertebral nerve block, a kind of regional anesthetic. Doyle had two small, flexible catheters inserted in her back, one on each side, that continually released medication over the course of a few days, a time period determined by the team. The catheters were connected to a softball-sized, portable bag of medication kept in pouches, which Doyle strapped around her waist.
Despite having opioids or painkillers on hand in case her postoperative pain became overwhelming, Doyle found that it was nearly nonexistent. “When I got home, I still wasn’t in pain. I mean, I’m toddling around — most people are down for the count for five to seven days, writhing in pain, can’t get out of bed, can’t move around; that’s just the nature of the mastectomy. Here, I’m hanging out with my kids, walking my kids to the bus stop, doing dishes the minute I get home.”
As Dangerfield explains, Doyle’s experience isn’t unusual: “Here’s someone who goes under, on a lot of different levels, a very significant surgery. She feels well enough to do [daily activities], as opposed to the patients who don’t get this [treatment] who are really laid up for a while and are not only miserable from the pain, but miserable from the side effects of the medication.”
Looking back, Doyle believes the multimodal approach was a kind of gift, a blessing even, that she learned was almost unique to her. “A few people — someone’s secretary or someone’s sister-in-law — would get diagnosed, and I would tell them all about this procedure,” Doyle recalls. “Of course, they had never heard of it, and I almost felt bad talking about it because I felt like it was a special gift I had been given. I guess [although] GW does them, not every hospital does.”
GW Hospital, the Acute Pain team explains, is one of the few institutions using this multimodal approach — but not because it’s so “super-secret and super-special that we’re the only ones who can figure it out,” Dangerfield says. The issue, he says, is a lack of education on pain treatment options: combinations of the regional anesthetics, ketamine infusions, IV therapy, anti-inflammatories, and muscle relaxants.
To combat that lack of knowledge, SMHS has made pain management a component of the medical curriculum. Students rotate with the team for two to four weeks, and Marian Sherman, M.D. ’99, assistant professor of anesthesiology and critical care medicine at SMHS, lectures on the topic. Likewise, the team, says member Jessica Mersinger, an R.N. at GW Hospital, is “approachable and willing to educate, so we have residents who rotate through the service, who work with us managing the medications, and they take that back to their colleagues, [such as] the orthopedic team.”
“The Pain Cave,” as the Acute Pain team office is known, also has a reputation for luring in GW Hospital health care staff through treats — especially Oreos — in order to discuss pain management options. “Even if it’s not an official consult, people will know who we are and stop us and say, ‘What do you think about this? Could I try this, could I try that?’” Dangerfield says. “It’s being that Pied Piper to get as many people as possible to do what we do.”
The benefits of the Acute Pain Management Service extend far beyond just mitigating suffering for those undergoing surgery; surgeons who use the Acute Pain team find that their patients’ satisfaction increases, as does their practice, and patients feel cared for, thanks to the service’s 24/7 availability by phone and counseling options. It’s what makes the program special, Dangerfield adds: GW Hospital not only provides for the service, but also provides for support staff — four nurses and two nurse practitioners — to make sure patients receive comprehensive care at all times. “It’s truly what sets us apart,” he says. The team plans to add telemedicine soon, as well.
“If all hospitals had an acute pain service that treated those patients [addicted to opioids] effectively, there would be a lot fewer patients going out on the street with Price Club-sized containers of opioids or going out and getting street drugs to treat their pain because the doctors didn’t treat it correctly,” Dangerfield says. “One mistake did not get us here, and one correction is not going to get us out. But if every hospital adopted what we did, it would be a big step in getting ahead of the initial problem.”